Children's Healthcare of Atlanta Cardiology Provider Referrals

Children's Healthcare of Atlanta Cardiology Provider Referrals
Please use one form per patient. If the patient needs to be seen within the next week, call 404-256-2593 and do not fill out this form.
Date

MonthDayYear
Date
Referral form completed by*

First NameLast Name
Direct contact phone number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Referring office preferred method of communication*

PhoneEmail
Patient's name*

First NameLast Name
Patient's date of birth*

MonthDayYear
Date
Parent/guardian name*

First NameLast Name
Mobile number*
Please enter a valid phone number.Format: (000) 000-0000.
Alternate number
Please enter a valid phone number.Format: (000) 000-0000.
Referring provider's name*

First NameLast Name
Office phone*
Please enter a valid phone number.Format: (000) 000-0000.
Office fax*
Please enter a valid phone number.Format: (000) 000-0000.
Referring provider status with patient*

Referring provider is patient's primary care providerReferring provider is NOT patient's primary care provider
PCP name
PCP phone
Please enter a valid phone number.Format: (000) 000-0000.
Reason for referral
If ordering full evaluation and treatment, fax relevant clinic notes or testing and patient demographics to 404-252-7431.

If ordering an EKG or Echo, the order and patient demographics must be faxed to 404-252-7431.
Comments: Note preferred provider and reason for preference, if applicable:
Have you sent all relevant clinic notes, patient demographics and relevant imaging/diagnostic tests?*

Yes, faxed previouslyYes, uploaded via accessCHOANo, but will send as soon as possible
Please indicate if the patient’s diagnostic testing related to this referral was performed at Children’s. If so, please do not fax these records*

YesNo
Should be Empty: